Three Months to Save the NHS

UK Policy Covid-19 Public Services

Three Months to Save the NHS

Paper
Posted on: 16th August 2022
By Multiple Authors
Na’eem Ahmed
Guest Author
Martin Carkett
Policy Lead, Science & Innovation Unit
Paul Blakeley
Life Sciences Policy Lead
Brianna Miller
Researcher
Nathan Lloyd
Researcher
Daniel Sleat
Head of Research Unit
Axel Heitmueller
Senior Associate Fellow
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    Executive Summary

    Executive Summary

    The National Health Service (NHS) is on the brink of disaster and the government must immediately prepare for an existential crisis this winter. The service is fast approaching what is likely to be the most challenging period in its 74-year history. A perfect storm of acute pressures driven by Covid-19, a resurgent flu epidemic and the indirect effect of the cost-of-living crisis will combine with the unprecedented elective-care backlog and a workforce that is already depleted and exhausted.

    The new prime minister will be announced on 5 September, leaving little time to prepare before winter. While Rishi Sunak has pledged to put the country on a “crisis footing” from the first day of taking office, there has been little detailed discussion between the two shortlisted Conservative candidates on plans to address the impending health emergency the UK faces.

    The NHS and social-care system is already in real trouble, as seen by the record ambulance-response times, growing waiting lists, increased staff absences and workforce burnout. With circumstances expected to deteriorate further over the coming months, the government must act immediately to avoid catastrophe. This call for immediate action has been echoed by the Chair of the Health and Social Care Committee Jeremy Hunt.

    Considering the situation beyond the NHS, both resurgent Covid-19 and flu pose a significant threat to the labour market and the economy at a time of growing economic instability. A recent report from the Bank of England found a staggering 17 per cent of the UK’s working population was self-reporting as long-term sick in the first quarter of 2022, with Long Covid making a growing contribution to this figure. It is vital therefore that we minimise the spread of Covid-19 and flu this winter.

    Last week, NHS England set out a package of measures to boost capacity ahead of winter, including plans to increase available hospital beds, bolster 111- and 999-response staff, expand international recruitment and provide more funding for mental-health services. While these are all helpful policies, they will be insufficient and the government must go further to support the NHS and help it manage the unprecedented pressures it faces this winter.

    Here, we set out our action plan to save the NHS this winter. We call for the government to immediately: focus leadership; minimise demand on the service; improve patient flow and efficiency; and maximise capacity. We propose 12 actions that will require the collaboration and commitment of national and local government, the NHS and the private sector – and which together will give the NHS the best possible chance to survive this winter.

    Focus Leadership
    1. Set up a winter-crisis taskforce and settle additional funding early.
    Minimise Demand
    1. Campaign for widespread and early Covid-19 and flu vaccinations across the NHS workforce.
    2. Extend public-facing Covid-19 and flu-vaccination strategies to all those aged over 18.
    3. Mandate FFP2/3 face-mask wearing for NHS staff in health-care settings.
    4. Be prepared to re-introduce the mandating of mask wearing on public transport and in confined spaces.
    Improve Patient Flow and Efficiency
    1. Improve the speed and consistency of access to primary care.
    2. Roll out technology to release capacity and manage patient demand.
    3. Increase support for social-care services and expedite patient discharges.
    4. Identify and enable the flexible use of regional surge capacity.
    Maximise Capacity
    1. Stand up a volunteer and reservist workforce.
    2. Expand use of private-sector capacity.
    3. Prioritise staff retention.

    The Health Service Continues to Feel the Effects of Covid-19

    Feeling the Effects of Covid-19

    In October 2021, we published Levelling Up Health Care: Build the NHS Back Better, which set out a path to alleviating the acute problems facing the NHS in the aftermath of the pandemic, as well as recommendations for implementing the structural reforms needed to put the service on a sustainable long-term footing.

    Almost one year on, the NHS is in an even more precarious position: over seven million people across the UK are waiting for elective treatments, accident-and-emergency (A&E) waiting times are almost at an all-time high (Figure 1) and cancer targets, among others, are not being met. More than 300,000 people are on the waiting list for cancer treatment in England, with nearly 40,000 waiting more than 62 days after a GP referral for suspected cancer.

    The strain on the NHS is not only impacting its capacity to deliver, it is also unsustainable for the workforce. In a report released on 19 July, the General Medical Council (GMC) found that the “risk of burnout is now the highest it has ever been” among the doctors surveyed and since it began monitoring these risks in 2018. There is also a significant workforce shortfall the service must contend with - in July, evidence in a Health and Social Care Committee report found there were significant staff shortages, including 12,000 hospital doctors and more than 50,000 nurses and midwives.

    Collectively, the data paint a picture of an extremely overworked and under-resourced NHS, heading into its most challenging time of the year.

    Figure 1 – A&E waiting times for both four hours or more, and 12 hours or more, are soaring above comparable levels seen in the past four years

    Sources:s NHS, Nuffield Trust

    Waiting Times on the Rise, With Regional Variations

    When considering the impact of rising waiting times, the regional perspective provides important context on the extent of the backlog and how specific trusts are failing to meet the needs of patients. NHS England is currently meeting appointments for general care within the target of 18 weeks in only 56.8 per cent of cases. While London’s percentage stands at 66.9 per cent, other regions are significantly lower with the South West on 61.3 per cent and South East on 64.3 per cent. The Midlands has the poorest waiting times, with its figure at 58.7 per cent, and the North West is on a par, at 58.8 per cent. The East of England figure stands at 59.5 per cent whereas the most effective region at meeting treatment waiting times on target is the North East and Yorkshire, but its 69.9 per cent success rate is not as high as figures had been in previous decades.

    A Winter Crisis of Unprecedented Scale

    A Winter Crisis of Unprecedented Scale

    The NHS always experiences rising demand over winter. Even moderately cold temperatures of between 5℃ and 8℃ result in increased illness and higher mortality while more time indoors leads to epidemics of seasonal illnesses. Meanwhile, a higher proportion of patients requiring longer stays in hospital means the service is left with less flexibility to manage the demand. But winter crises have only become a perennial problem in recent years.

    Prior to 2010, NHS funding rose broadly in line with rising demand and, although winter months saw increased pressures, the service was largely able to avoid the more recent crises we have become accustomed to. Since 2010, with the exception of the additional support provided to combat Covid-19, the NHS has been subject to a period of historic funding squeezes relative to demand, which has continued to rise. This has been a decisive factor in the recurrent winter crises, which are becoming ever more acute year on year. In 2022/2023, this trend will only be exacerbated.

    This winter will bring a perfect storm, resulting in unprecedented demand and reduced capacity, which will combine to create the worst winter crisis in the NHS’s history. The factors contributing are:

    • Covid-19 wave: Omicron BA.4 and BA.5 are the dominant Covid-19 subvariants of concern in the UK, proving more infectious than previous variants, although not causing more severe illness. They are nonetheless likely to cause another wave of Covid-19 this winter, which will drive up NHS demand. Australia and New Zealand are already experiencing winter spikes in cases and deaths caused by BA.5. The FIFA World Cup starting in November this year will involve crowds – some who will travel back to the UK – in confined spaces and this could potentially add to a spike in Covid-19 cases and other respiratory infections, as was experienced during the 2021 European football championships.
    • Severe flu epidemic: Non-pharmaceutical interventions (NPIs) for Covid-19 have resulted in very low levels of flu around the world during the past two years. But now that NPIs are no longer in place in the UK, experts believe there is likely to be an abnormally large surge in cases this winter as is currently being seen in the southern hemisphere, particularly Australia (Fig. 2). Meanwhile, flu-vaccine uptake has decreased year-on-year to date compared to 2021.
    • The cost-of-living crisis: Energy prices are set to rise significantly over winter, hitting the poorest households hardest. Coupled with inflation, already at 9.4 per cent in the UK and set to increase to 13 per cent this year, according to the Bank of England, many people will be left unable to afford heating, exacerbating illnesses caused by the cold weather. Others, who may in the past have opted for private health care, may no longer be able to afford this option, adding to NHS demand.
    • Backlogs: The NHS is still reeling from the aftereffects of Covid-19, with record backlogs meaning that more than seven million people are waiting for elective care across the UK, a figure that is stretching government targets for increasing this activity. Rising winter pressures will likely lead to a reduction in elective-care activity, adding to the existing – and considerable – backlog.
    • Depleted and exhausted workforce: The NHS is also facing significant capacity challenges. Vacancies in the NHS have now topped 110,000. Morale is at an all-time low, with 50 per cent of staff in one survey saying they have considered leaving the profession in the past 12 months and one-in-five saying they are actively looking to leave. Meanwhile, the number of staff retiring has increased 50 per cent year on year. In addition, compared to other countries, the UK has fewer hospital beds, with occupancy rates exceeding safe levels.

    Figure 2 – Australia has already experienced record cases of influenza type-A cases this winter

    Source: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00503-5/fulltext

    The Government Must Act Immediately to Avoid Catastrophe

    Act Immediately to Avoid Catastrophe

    To date, the government has failed to prepare adequately. Neither Rishi Sunak nor Liz Truss has set out detailed commitments to address either the existing or upcoming challenges the NHS faces, despite the current Secretary of State for Health and Social Care Steve Barclay and the Chair of the Health and Social Care Committee raising significant concerns and calling for immediate action.

    NHS England has set out a winter plan to boost capacity in preparation. While this includes some helpful measures to increase hospital beds and workforce capacity and improve ambulance-response times and patient-discharge rates, it will be insufficient to address the magnitude of the challenge. Moreover, the plan is overly focused on input targets rather than outcomes. It fails to adequately set out preventative measures to pre-emptively reduce demand, such as targeted vaccine strategies, or to address the emergency workforce supply required immediately to support the NHS through winter. Additionally, the plan is not supported by the additional funding that will undoubtedly be necessary.

    Failure to respond more robustly will be catastrophic. The NHS is already on its knees and the expected surge in demand over winter will bring it to the point of collapse. A&E waiting times will worsen, hospital-bed capacity will be overwhelmed, and the elective-care backlog will continue to grow, leaving an increasing number of people without the treatment they need. Ultimately, the NHS will no longer be there at the point of need – and lives will be lost unnecessarily.

    Moreover, not containing the widespread resurgences of both Covid-19 and flu – a challenge that has already arisen in the southern hemisphere – is likely to have a significant impact on the UK’s workforce and the economy at a time when the country can ill afford this.

    The government must prepare – without delay – more comprehensively for the impending crisis and take urgent action to:

    • Focus leadership.
    • Minimise demand on the service.
    • Improve patient flow and efficiency.
    • Maximise capacity.

    Here, we set out 12 recommendations to be taken forward immediately to support these objectives – and give the NHS a fighting chance this winter.

    Focus Leadership
    1. Set up a winter-crisis taskforce and settle additional funding early.

    First and foremost, leaders need to get a grip of this crisis. Rapid delivery of the recommendations below will require political will, strong leadership and cross-departmental working, as many of the proposed actions cut across traditional organisational boundaries.

    This crisis is reminiscent of the challenges faced by the government in its response to Covid-19, specifically to develop, procure and roll out novel vaccines at speed. To address this one, the government should adopt the model it created for Covid-19 and the Vaccine Taskforce, and establish a dedicated winter-crisis taskforce to oversee delivery of the following recommendations to save the NHS. The taskforce should be headed by a dedicated and experienced Senior Responsible Owner (SRO), who has direct accountability for delivery at the centre and which can hold integrated care systems (ICSs) to account for that delivery at an operational level. The government should similarly appoint a minister with specific responsibility for overseeing this agenda, breaking down barriers between departments and empowering officials to get things done in a similar vein to the former Minister for Covid Vaccine Deployment. However, the minister must have clear remit and responsibilities, and sufficient power to be effective, which should include access to funding.

    We recognise the measures below will require funding that will not be included in the Department of Health and Social Care’s (DHSC) Spending Review 2021 settlement, and that it will come at a time when the NHS is already trying to find money from within existing budgets to fund recent pay increases.

    Over the past decade, the Treasury has provided the NHS with additional funding (typically in the hundreds of millions) to manage winter pressures, either through additions to baseline funding, “top-up” settlements during autumn fiscal events or via exceptional Covid-19 funding. Given the extreme pressures now faced by the NHS, the Treasury will again be required to provide additional funding in order to avoid significant disruption and a rise in excess mortalities.

    In the past, additional winter funding has been typically settled in November but this will be too late this year. If the government takes forward an emergency budget as pledged by Liz Truss, then reaching an early-winter settlement with the NHS should be a top priority as part of this, alongside additional support to help manage the energy crisis, as we are separately calling for. These two priorities should not be considered in isolation. The level of support on energy bills will have direct impacts on NHS demand this winter, given the causal link between cold weather (or the inability to heat homes) and poverty, and increased sickness and mortality.

    Minimise Demand
    1. Campaign for widespread and early Covid-19 and flu vaccinations across the NHS workforce.

    The importance of protecting staff and the vulnerable individuals they come into contact with is essential to maintaining capacity and reducing demand on frontline NHS services. More than 45,000 NHS staff (almost 4 per cent) were absent due to Covid-19 during the worst of the January 2022 peak. With Omicron still circulating and high rates of flu forecast this year, ensuring high Covid-19 and flu-vaccines uptake among NHS and social-care staff will be critical to avoid unmanageable levels of staff sickness.

    The announcement of Covid-19 booster doses – which includes the now-approved bivalent jab that targets the Omicron variant – being made available for frontline health and social-care staff is welcome but it will require a supportive information campaign to overcome messaging fatigue, and to reinforce the protective effects for both staff and patients. The campaign should avoid any suggestion that boosters are mandatory, given previous tensions associated with vaccination as a condition of deployment.

    Ensuring widespread coverage and early uptake is important. Any campaign should build on lessons and models that have been used effectively in previous successful vaccination distribution, particularly the use of data to identify the most at-risk groups. The campaign should incorporate: joint delivery of Covid-19 and flu vaccines where possible and where it is safe to do so; the use of accessible vaccination sites, for example those that provide easy access for night-shift workers; and collaborations with unions, clinical leaders, staff networks and faith/pastoral-care leads to increase engagement and provide reassurance across the workforce.

    1. Extend public-facing Covid-19 and flu-vaccination strategies to all those aged over 18.

    There is likely to be a spike in both Covid-19 and flu cases that will add strain to an NHS already stretched to its limit. To mitigate this extra pressure, government strategy must also include measures to reduce the spread of these diseases. The first line of defence is vaccination. The Covid-19 and flu strategies that already include free vaccinations for the over-50s (and those considered to be or in frequent contact with the vulnerable) should be extended to all people aged 18 and over. Rapid development and approval of flu/Covid-19 combination vaccines, as being trialled by Novavax, would accelerate this process.

    Given the strain on the health system and the shortage of staff, there is a tension between allocating sufficient resources to a vaccination campaign and taking staff away from their positions in hospitals or GPs to administer the jabs, therefore inadvertently adding to workforce-capacity strains. For this reason, flu and Covid-19 vaccinations should be co-administered where possible. Moreover, vaccinators recruited during the Covid-19 rollout should be re-engaged to prevent existing clinical staff from being redeployed. This extra-workforce group includes paramedics, student doctors, and retired NHS doctors and nurses. Pharmacies should also continue to be an integral part of vaccination campaigns.

    Innovative delivery models from the previous rollout, such as “pop-up” vaccination sites in shopping centres and places of worship, roving vaccinators to target nursing homes and multi-generational households, and multilingual and multichannel communications to reduce inequality, should all be redeployed.

    Strategies should also be targeted to utilise available data to identify and focus on unvaccinated individuals – and areas – most at risk. The UK has been leading the world in tracking Covid-19 through wastewater. More recently, polio was detected in sewage and a localised vaccination campaign in London was initiated as a result. It is also possible to track flu and anticipate likely demand for NHS services locally. However, investment in wastewater testing is falling behind other parts of the world, despite it being one of the most promising and versatile legacies of the pandemic.

    The UK Health Security Agency should therefore work with the NHS and local authorities to establish a near-real-time Covid-19 and flu dashboard to track outbreaks. The NHS should reinstate, where it is not already in place, the principle of mutual aid to support providers within an integrated care system that is facing particularly high demand. Wastewater data should also be made publicly available (like a public-health weather forecast) so that citizens can take appropriate decisions on, for example, taking public transport, home working and activities in crowded public spaces.

    1. Mandate FFP2/3 face-mask wearing for NHS staff in health-care settings.

    Community mask wearing has been shown to substantially reduce the transmission of Covid-19 and other respiratory infections. Face-mask wearing for staff in health-care settings will be an important method of reducing the spread of both Covid-19 and flu, protecting staff and patients equally.

    Health-care workers are already required and visitors encouraged to wear surgical face masks. However, emerging evidence suggests that upgrading face masks to filtering facepiece (FFP2 or FFP3) respirators for health-care workers on Covid-19 wards has been shown to dramatically reduce hospital-acquired Covid-19 infections. However, several NHS Trusts have diverged from the central guidance regarding mask type. This is why upgrading to FFP2 or FFP3 masks should be mandated across all NHS trusts to maintain staff and patient confidence. The installation of air filters across Covid-19 and flu wards could also help reduce hospital-acquired transmission.

    A further education campaign should be launched around infection, prevention and control, including fit-testing of masks and reinforcement of good hygiene practices to further reduce hospital-acquired transmission. Staff should also feel supported to take sick leave, as required, to prevent the spread of infection, which would have a greater impact on capacity. The DHSC must also consider measures that similarly protect contracted workers who are critical to the health-care system, but may not benefit from traditional safety-at-work protections.

    1. Be prepared to re-introduce the mandating of mask wearing on public transport and in confined spaces.

    The strategic implementation of mask mandates should be considered for this autumn and winter. As we have recommended previously, at times of high Covid-19 transmission, or when there is an elevated general risk (such as when a new variant emerges), or a higher likelihood of severe outcomes (when an outbreak coincides with the flu season), the government should be prepared to reinstate the mask requirements that were in place. This would mean mandatory mask wearing on public transport and most indoor public venues (excluding hospitality) during the winter. The government should reserve the capability to activate such a plan quickly, if necessary.

    In Germany, the government is already considering this option, with mandatory mask wearing in indoor public spaces potentially to return ahead of the upcoming flu season and likely rise of Covid-19 cases. FFP2 masks are already mandated – at a minimum – on German public transport.

    At a time when people want to feel like the world is moving on from Covid-19, the messaging around the re-introduction of mask wearing will play an important part in the strategy’s effectiveness. Any mandatory re-introduction should be supported by a government-led communications campaign based around “doing your part for the NHS” by wearing a mask and getting vaccinated.

    Improve Patient Flow and Efficiency
    1. Improve the speed and consistency of access to primary care.

    To effectively manage winter pressures, the NHS must be able to effectively manage the flow of patients through primary, secondary and community care. This means ensuring the right patients are treated in the right place at the right time based on insights from data. Access to primary care continues to pose a major problem, with nine-in-ten patients in some parts of England struggling to access their GP and up to a third of patients abandoning calls to 111. As a result, these patients are not being triaged effectively and are likely to end up in A&E instead, placing additional pressures on secondary care.

    The reasons for these increasing demands are multifaceted, but include declining GP numbers alongside stark increases in registered patients – who have risen by almost one million in England in the past year – and higher patient demand, with appointments in the first six months of 2022 outstripping last year’s figure by 8 per cent.

    There are many longer-term proposals to improve primary care as part of broader NHS reforms. But action is needed now to improve patient access and manage secondary-care demand in the run up to an extremely challenging winter. The government should immediately:

    1. Roll out technology to release capacity and manage demand.

    Technology and innovation are central to unlocking greater efficiency, and improving patient care and outcomes. It is therefore disappointing that the NHS England winter-resilience plan published last week does not mention innovation once. While there are many long-term initiatives underway to improve use of proven technologies, the NHS must focus in the short term on identifying and deploying those that can relieve immediate pressure on frontline services and combat the growing demand for bed space.

    We suggested key areas for consideration in Levelling Up Health Care: Build the NHS Back Better in October 2021. The immediate priorities must be:

    • Expanding virtual wards and the use of technologies to support home-based care. Virtual wards proved effective during Covid-19, saving 300 bed days over a single three-week period, while remote patient-monitoring apps, such as those produced by the company Huma, allowed the number of patients being monitored at home to more than double. Integrated care systems must utilise the £200 million of funding they have received for 2022/2023 to expand virtual wards and adopt enabling technologies in order to support more patient care at home.
    • Use proven AI-enabled technologies to increase efficiency. Platforms such as DrDoctor can help to more effectively manage outpatient appointments, which drive up to 85 per cent of hospital-based activity, while AI chatbots, such as Wysa’s etriage system, can guide patients through stages of self-referral to release clinical-referral admin times. AI has already been used in Staffordshire to reduce A&E admissions by 35 per cent and it can also be used for diagnostics. For example, Kheiron Medical Technologies’ Mia Triage platform can expedite breast-cancer screening and diagnosis while DeepMind’s algorithms have been used to speed up diagnosis of eye and kidney diseases.

    The NHS must make more widespread use of these technologies to increase efficiency and release capacity to help manage winter pressures.

    1. Increase support for social-care services and expedite patient discharges.

    Social care can help to reduce hospital admissions, decrease patient length of stay and increase discharge rates – all of which are vital to managing winter pressures on the NHS. However, the delay in discharging patients from hospital is often a result of a lack of suitable social-care support, despite the latter costing one-sixth of the equivalent to keep a patient in a hospital bed. And the Chief Executive of NHS Providers Chris Hopson has issued a stark warning about the difficulties posed by the 20,000-plus medically fit patients who remain in hospital.

    If the NHS is to effectively manage winter pressures, social care must urgently receive further support to manage demand at the “back end” of the system and to free up capacity in secondary care. Liz Truss has announced her intention to provide £13 billion of funding to adult social care if elected. A significant portion of this funding must become available immediately to increase social-care capacity and prevent a further exodus of staff, with vacancies having risen by 52 per cent in the past year.

    At the same time, the NHS should rapidly roll out initiatives that can expedite safe patient discharge and increase acute-service capacity. Such initiatives could include safely extending roles among current staff, for example, radiographer-led discharge for minor musculoskeletal injuries, and extending remote patient monitoring to alleviate pressure on emergency departments. The third sector has an important role to play in supporting patients getting home safely. The Richmond Group, a collective of health charities in the UK, can support the NHS and social care by scaling safer discharge initiatives led by their members (for example, the support at home initiative led by the British Red Cross). A 2018 patient survey of patients led by the Care Quality Commission (CQC) reported that nearly three in four patients that were delayed in discharge were due to wait for medicines. Scaling of initiatives such as same/next day medication home-delivery services in Cambridge may help mitigate these delays.

    Around 30 per cent of patients who remain in hospitals could be safely discharged at any point in time, with previous day-of-care audits indicating that up to half of them fail to be discharged for reasons within the control of the hospital. This type of information should be regularly collected, with these issues demanding as much attention as social care to ensure hospital capacity is maximised.

    1. Identify and enable the flexible use of regional surge capacity.

    Regional identification of surge capacity, such as available acute- and intensive-care beds if mutual aid is required. This may also include the re-commissioning of regional surge hospitals ("Nightingales") as step-down/interim-care facilities to relieve pressure on hospitals. Criteria for transfer to these step-down facilities should be supported with clear clinically led discharge guidance to prevent bottlenecks. The NHS could collaborate again with the Ministry of Defence in supporting this service.

    This should be supported through mobilisation of the workforce across geographies. As an urgent priority, pilots of the digital staff passports should be accelerated. This will enable staff to both help across geographies that have acute requirements and to support backlog reduction. Such a scheme adopted universally would also help reduce the bureaucracy when it comes to staff re-enrolling at different hospitals during clinical training.

    Digital workforce-management tools, such as those being offered by Patchwork Health (already being used by more than 60 NHS partners) to better and more flexibly manage staff, should also be employed more widely.

    Maximise Capacity
    1. Stand up a volunteer and reservist workforce.

    A national crisis requires a national call to action. The NHS and social-care system benefits from the important contribution of volunteers and reservists, as seen during the first wave of Covid-19 when more than 700,000 citizens volunteered in four days.

    While relying on volunteers should not be a general expectation and is not sustainable, this step will be necessary this winter, given the expected demand and capacity issues. However, volunteering and reservist resources should be used effectively to minimise the burdens on health-care administrators who deploy them and to ensure they have a positive experience.

    The national vaccination campaign for Covid-19 is the blueprint. It requires “training to task”, in other words giving each volunteer a single, specific responsibility, with high-quality training provided on the task. The selected responsibilities should alleviate specific pressure points in the system, for example through the use of ward volunteers to improve the patient experience and free up capacity for health-care professionals to focus on clinical duties. Data show that every volunteer can help free up time equivalent to almost 30 minutes per nurse per day as well as to expedite patient discharges by 44 minutes. Such gains – no matter how marginal – will be vital if the NHS is to withstand the pressures of the coming winter.

    In addition, the mobilisation of health-care students through paid opportunities as vaccinators during the winter holidays could also boost capacity to deliver immunisations, as was the case during the pandemic. More generally, we may want to look at a structured and sustainable CareFirst-type programme to increase the number of domestic staff by building on the National Citizen Service for 16- and 17-year-olds and similar schemes in many European countries.

    1. Expand use of private-sector capacity through time-limited partnerships.

    As we set out previously, taking advantage of private-sector capacity is one way to alleviate some of the acute pressure on the NHS in the short term. Fully committing to a short-term partnership with the private sector is essential to bringing down the backlog as quickly as possible. In October 2021, we spoke with contacts in the private-health sector and found the service could, by forming the right partnerships, achieve 150 per cent of pre-Covid independent-sector NHS capacity quickly.

    Although the government has since agreed to work with the private sector to help with capacity during Covid-19 surges, private-sector capacity could still be used more effectively to help reduce the backlog – and prevent it from getting worse this winter.

    For example, The Telegraph reported in May 2022 that a poll of independent-sector providers (representing 150 locations across England) revealed that one-in-four had not been involved in any discussions to make use of private-sector capacity to support the NHS for 2022/2023.

    Although full use of the independent sector would greatly speed up the backlog recovery, it is unlikely such high levels of collaboration can be achieved. There is still a strong political stigma around deep public- and independent-sector partnerships. But if some level of private-sector capacity is drawn on for a limited period, with clear targets, it would support the NHS in achieving its goal much quicker. The aim of such partnerships should be to use spare private-sector capacity to support the NHS as it works through the elective-care backlog, rather than as a solution to the chronic problems the service faces – an issue that requires much deeper reform. The partnerships should be built upon these core principles:

    • Time specific: Collaborations should be agreed upon for a specific period of time, for instance one year. This will support a clear focus on delivery during the specified period and make clear the specific partnership is in place to tackle a specific issue.
    • Targeted: The support the independent sector provides should be focused on critical elements of the backlog.
    • Transformative: Independent-sector provision must add to NHS capacity to drive up delivery, and be built around a core set of deliverables.
    1. Prioritise staff retention.

    Staff turnover is on the rise, with 140,000 (around 11 per cent) hospital and community-health staff having left active service in the year to September 2021, and a further one-in-five NHS staff reported to be actively looking to leave. A 50 per cent increase in retirement levels over the past year is also of concern. It will be imperative to retain as many trained staff as possible to support capacity, which is also financially more efficient than attempts to boost recruitment.

    Financial measures, such as the re-evaluation of current pension arrangements to ensure senior and experienced clinicians are incentivised to remain and to support backlog recovery, should be a priority, as called for by Jeremy Hunt. Top-up payments to staff in fields of particular stress, such as social care, first responders and community nursing, should also be considered to help during winter and support staff during this cost-of-living crisis.

    Wider workforce flexibilities could also help to ensure continuity of service. For example, health-care providers should be supported in setting up collaborations to provide subsidised, on-site childcare facilities, especially important during school holidays and the Christmas period.

    Conclusion

    Conclusion

    The NHS has gone above and beyond the call of duty to support the country through its most challenging period in a generation. But the service is still suffering from Covid-19 aftershocks and remains under immense pressure. Primary-care access, waiting lists and emergency-response times are at the forefront of public concern and point to a health service in crisis. This will only worsen in the coming months as the usual winter pressures and additional strains unique to 2022/2023 materialise. The threat level to the NHS today has been described as existential.

    The weary and depleted workforce will need to dig deep in the months ahead to get through what will be the most demanding period in the NHS’s history. NHS England has set out a package of measures to boost capacity ahead of winter, which will help but will be insufficient to meet the severity of the challenges. The government must do whatever it takes to support the NHS through this period and act immediately to avert an unmitigated disaster. Failure to do so will result in the breakdown of the NHS as we know it, with a collapse in vital services and a rise in adverse patient outcomes, including adding to the number of excess deaths.

    Lead Image: Getty Images

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